Exam 1- learning objectives Flashcards
Review the anatomy and physiology of the skin and mucous membrane.
Epidermis -outer layer-protection
Dermis-,middle layer-support/protection
Subcutaneous layer- insulation, supports, energy storage
mM-lubricates and protects organ cavities from invasive pathogens
Identify risk factors which contribute to impaired skin integrity.
Age
* Lifestyle variables
* Changes in health state
* Illness
* Diagnostic measures
* Therapeutic measures
Describe the system for staging pressure ulcers.
1-looks/feels red and warm.might burn hurt/itch.Erythma
2-partial thickness skin loss-skin starts to peel off
3-crater like appearance due o damage below surface-full thickness skin loss into dermis but not muscle or bone
4-The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved
Review phases of wound healing.
Homeostasis-Stop bleeding- vasoconrticiton to block drainage-
inflammation-veins dilate again, causing neutrophils to enter/destroy bacteria, brings wbc to area to kill off infection
proliferation-fill wound-granulation tissue is present, new bv are formed, rebuilding the old tissue
remodeling-the new tissue slowly gains strength and flexibility. Here, collagen fibers reorganize, the tissue remodels and matures and there is an overall increase in tensile strength
Differentiate between the different types of wound drainage.
Serous-white serum
serosanguineous- serum and blood
Sanguineous-blood
purulent-pus
Describe potential complications of wound healing.
Dehiscence-Partial or total
separation of wound
layers
Evisceration-Protrusion of viscera (internal
organs) through incision-organ protrudes out
Indicate factors affecting wound healing.
- Desiccation
- Maceration
- Pressure
- Trauma
- Edema
- Infection
- Excessive bleeding
- Necrosis
- Biofilm
- Age
- Circulation / Oxygenation
- Nutritional Status
- Wound Etiology
- Medications
- Immunosuppression
Summarize the factors that are components of the Braden Scale for Predicting Pressure Sore Risk.
Sensory Perception-LOC
* Moisture-skins exposure to moistue
* Activity-how often the move out of bed
* Mobility-ability to change position
* Nutrition
* Friction and Shear
Describe nursing interventions that will prevent skin breakdown and support wound healing.
Drains
wound dressings-protect wound
removing debris
provide moist wound healing envirment
proper nutrition
Identify risk factors for acquiring an infection.
Age
poor nutrition
stress
no sleep
disease
medical history
Review the chain of infection.
Pathogen-bacteria
resevior-where the pathogen lives
portal of exit-where exits body
mode of transmission-direct/indirect contact/vector
portal of entry-where enters body
susceptible host- anyone who will harbor disease
Outline nursing assessments for identifying an infectious process.
Fever
pain/tenderness
redness/swelling
tachycardia/penia
malaise-dsiconfort
WBC count
List interventions that break the chain of infection.
hand hygeine
vaccinations
covering coughs/sneezes
standard precations
contact isolation
ppe
cleaning/disinfecting equipment
Describe isolation precautions outlined by the CDC.
contact-gloves and gown-is contact with body secretions, make and eyewear
droplet-within 3-6feet,use standard precations and use mask
airborne-every time, gown gloves and n95 mask
blood borne-gloves,mask,eyewear,gown
Identify physical and psychological effects of the infectious process.
fever, headache, dizziness, rash, inflammatory response
delirium, mood disorder ,generally a worsened mood is a result of an infection
List pharmacological approaches to treat and/or prevent infections.
antibiotic
antiviral
antifungal
antipastic
vaccines
Identify the components of the nursing process.
Assessment
diagnosis
planning
implementation
evaluation
List resources needed to complete a patient database.
Subjective
past/current health
treatment history
genetic history
family history
what’s going wrong
objective
anything you can find that may be abnormal, any findings/readings that prove what’s wrong
Differentiate between a medical and a nursing diagnosis.
A medical diagnosis describes a disease, illness, or injury, and the purpose is to find pathology
. A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently.
Explain the process of goal setting and outcome identification.
SMART goals
Specific
measurable
attainable
relevant
time based
this will create a goal and a set time to reach the goal that will get the patent where they need to be in order to leave care
Identify factors that are considered when prioritizing care needs.
ABC
self actualization
self esteem
love/belonging
safety/security
physiological needs
Select nursing interventions to support goal achievement.
assessing health status, preventing and treating illness or disease, and promoting health.
Describe the relationship between patient outcomes and evaluation.
Terminate plan of care when expected outcomes are achieved
- Modify the plan of care if there are difficulties achieving outcomes
- Continue the plan of care if more time is needed
- The nurse should re-examine and revise the plan of care based on patient
progress. Always ASSESS for
effectiveness!
Identify PN versus RN roles when using the nursing process.
PNs can only provide care when they are supervised by an RN and are expected to report changes in the patient’s care to their superiors. Generally, PN duties include:
Taking medical histories
Checking vital signs
Administering medications
Comforting patients
Assisting with administrative tasks
Supervising Unlicensed Assistive Personnel
Identify different frameworks used for organizing data.
mallows heiracht of needs
data collection in predetermined categories
gives specific way to think to get data to observe
